<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005476
Report Date: 04/19/2024
Date Signed: 04/19/2024 04:16:05 PM

Document Has Been Signed on 04/19/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELS CARE GUEST HOMEFACILITY NUMBER:
306005476
ADMINISTRATOR/
DIRECTOR:		JABONERO, JANICEFACILITY TYPE:
740
ADDRESS:10212 MALINDA LANETELEPHONE:
(714) 244-5885
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 6DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:13 PM
MET WITH:Janice JaboneroTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Janice Jabonero and discussed the purpose of the inspection.
LPA reviewed Infection Control requirements. At about 2:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 2-bathroom, one-story house with attached garage that is being used for storage. There is a back yard with a patio cover for the residents. LPA and AD observed 2 staff and 6 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 106 degrees F and 107 in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen, after corrections. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 3:00PM, LPA reviewed 6 resident files and 2 staff files, interviewed 6 residents and 1 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on observation, the lock for the knife drawer in the kitchen was not present and could not be located by staff, leaving the knives accessible to residents some of whom have dementia.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/19/2024 04:16 PM - It Cannot Be Edited


Created By: Sean Haddad On 04/19/2024 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS CARE GUEST HOME
FACILITY NUMBER: 306005476

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the lock for the knife drawer in the kitchen was not present and could not be located by staff, leaving the knives accessible to residents some of whom have dementia, which poses an immediate safety risk to persons in care.
POC Due Date: 04/20/2024
Plan of Correction
1
2
3
4
During the inspection, the licensee found another lock and secured the knives. Licensee stated they will retrain staff on securing dangerous items and reporting safety issues to the administrator and will submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2